35-199 (9) SECTION'8 --,CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
1 r
Address Expiration Date
Signature Telephone
�9"R gistered HomelmprovemenfContractor ,„ '" , q,r ,. ,r°� ' Not Applicable ❑
�t£.Y.Lt
17, < <� ' 1•-'J. i i 47
Company Name Registration Number
Address Expiration Date
Telephone___
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... Q No...... ❑
M ;
1�. -T3,om�O�w�nex�Exempnon _
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780 Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s)who own a parcel of land on which he/she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm
structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local "Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
ION'5 `,DESCRIPTION OF PROPOSED WORK(checkxall applicable)
p
..=w=a»zs.-.x,.yw•.a«e.,.rta va.a..�+�r s r ,s..
r,
New House ❑ Addition [ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks wV Siding[ ] Other[ ]
Brief Description of Proposed Work: . ` r'r` '�� . - 1�� -� ����'� i �� �«•�',+;t, l�r� l
i
Alteration of existing bedroom Yes ./,No Adding new bedroom Yes i No �.
Attached Narrative ❑ Renovating unfinished basement Yes __J,_No
Plans Attached Roll ❑ • Sheet,Pf y
s If N'ew housee3and or.addifidij toWezistih d[1_§ih� komplete th'e:followin_�:
a. Use of building : One Family / Two Family Other
b. Number of rooms in each family unit:_ Number of Bathrooms___
c. Is there a garage attached? '
d. Proposed Square footage of new construction. '`!_ G'. t�_ Dimensions 1,
r
e. Number of stories? �_-
f. Method of heating? „ Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. .J't > Mascheck Energy Compliance form attached? t4 e
h. Type of constructions �+
i. Is construction within 100 ft. of wetlands?_ Yes _ No. Is construction v,ithin 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? _ f. Yes __ No .
I. Septic Tank City Sewer_ Private well City water Supply
ION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNEaS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize L' " _� to act on
my behalf, in all matters ;u,GLi,u �o uLl��orized by this building 'AFNiication.
Signatu e of Owner Date
.- _ as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
f
Signature of Owner/Agent ` Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size , �� UCH -
Frontage
j
Setbacks Front
Side L: ',`�- R: L: i R:`) �0
Rear L10
Building Height
Bldg. Square Footage yi %
Open Space Footage %
_
(Lot area minus bldg&paved NCIP 1)i 1:
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW �', YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO `•, DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF-YES, describe size, type and location:
�'3.
City of Northampton Status of Pet I 1 ih '
A1-2,1 1r ^--"
Building Department CurbCut117;.v
212 Main Street Sewer/,Sep re"
Room 100 WWe11,, va"
Northampton, MA 01060 TwO is-on ;fr e
D
phone 413-587 1240 Fax 4 13-587-12 72 PIoISlte P"ans � �.
Other Speci;fyw Wo�
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address.
This section,to_be,completediby office
Map Lot Unit
Zone � Overlay District
Elm St. District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
` f
Name(Print) C,:rren; %1a i,n;Address:
C)----- --------- - -- - -
Signature
2.2 Authorized Agent:
_ /' 1
Name (Print) •_, j l CL,rrent Mai'ing address: —
Signature Teleph one
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit_applicant
1. Building _ r (a) Building Permit Fee
%- Ele rical 7 (b` aim?ted Total Cost of
Construction from (6)
3. Plumbing f tilt C __ Building Permit Fee
4 Mechanical (H'JAC; -----------_--
5. Fire Protection -
6. Total = (1 + 2 + 3 + 4 + 5) c l t lj)� —_ Check Number 3 i5 >
This Section For Official Use Only
Building Permit Number: Date Issued: —_
Signature: ------ --- —— — ---
Building Commissioner/Inspector of Buildings Date
-0 ft
File #BP-2003-0947
APPLICANT/CONTACT PERSON Mark Sarafin
ADDRESS/PHONE 81 Russellville Road (413) 527-7812
PROPERTY LOCATION 1144 BURTS PIT RD
MAP 35 PARCEL 199 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 18 X 8 KITCHEN BASEMENT ENTRANCE& 18 X 12 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 053434
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 7P ESENTED:
Approved i, Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project:_ Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
Nom..., vrQC��r7OtJ
ZONING BOARD PERMIT REQUIRED UNDER: §�Je Z
0,-
Finding Special Permit Variance* ���
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability _ Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street C ssion
Signature o uilding Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.